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Group says EMTALA violations frequent

Hospitals in nearly every state in recent years have violated a federal law prohibiting them from dumping patients, leading to people with medical emergencies being improperly screened or refused treatment altogether, according to a recent report from the advocacy group Public Citizen.

In its sixth in a series of reports on patient dumping, Public Citizen found that 527 hospitals violated the 1986 Emergency Medical Treatment and Active Labor Act (EMTALA). Taking data from all six reports into account, more than one in five hospitals throughout the country have violated the law since it was passed. The data suggest that most hospital staff are familiar with the law but break it anyway, says Sidney Wolfe,
MD, director of Public Citizen’s Health Research Group.

"It’s distressing that this law has been in place for 15 years and hospitals are still flouting it," he says. "The government needs to do more to force hospitals to comply. People shouldn’t be denied desperately needed emergency medical care when they go to a hospital. Failing to impose fines on most hospitals violating the law amounts to an invitation to dump sick patients."

Some administrative problems

Most of the violations cited in the current report were confirmed in 1997, 1998, and 1999, although a few were confirmed in 1996 and 2000. Not all the hospitals violating the act actually dumped patients; some violations were administrative in nature, such as omitting documentation or failing to post signs spelling out patients’ rights. The report lists the name of each hospital, the nature of the violation, and any fines assessed against the hospital. Of the 500 hospitals that had confirmed violations in 1997, 1998, 1999, and were eligible to be fined, only 85 (17%) had been fined as of April 2001.

Highlights of violations

According to records reviewed by Public Citi-zen, hospitals in 46 states, as well as the District of Columbia and Puerto Rico, were cited for violations. States with no confirmed violations were Delaware, Hawaii, New Mexico, and Wyoming. Here are some of the report’s key findings:

• For-profit hospitals had a significantly higher rate of violation (1.7 times higher) than not-for-profit hospitals.

• Up to one-third of surveyed emergency room registration staff recently told the U.S. Department of Health and Human Services’Office of Inspector General that patients might be asked for insurance information before a screening is provided or while it is taking place,and 35% said they contact health plans for authorization of screening exams at some point. These actions violate the law if they delay treatment.

• Hospitals are being fined more than in previous years. Civil money penalties increased from $130,000 in fiscal 1988 to more than $1 million in each of 1998, 1999, and 2000. However, most hospitals with confirmed violations are not fined.

Even when a hospital is fined, Wolfe says the amount is paltry.
"The sad truth is that it’s cheaper for a hospital to break the law and pay a fine than to treat an uninsured patient," Wolfe says. "Hospitals know that the risk of getting caught is low and, even if they are caught, the risk of being fined is even lower, and the fines are minuscule compared to hospitals’ operating budgets."

These are some of the more egregious examples of patient dumping in the report:

• A mentally retarded patient was brought by ambulance to Mercy Hospital in Merced, CA, with symptoms of abdominal distress and shortness of breath. An on-call surgeon repeatedly refused to come to the hospital to treat the patient, who subsequently suffered a cardiac arrhythmia and died despite a resuscitation attempt. Documentation revealed that the surgeon made disparaging remarks about the man’s mental retardation, including the statement that "no one would miss him if he died." The man had lived in a board-and-care home for 15 years. As of April 2001, the hospital had not been fined.

• A woman who went to Baptist Hospital in Miami was found to have a large mass in her lower abdomen and an elevated white blood-cell count, indicating she might have an infection. She was admitted for surgery, but before it occurred, the surgeon asked her for a deposit. The woman said she didn’t have the money, so the surgeon ordered the patient to be discharged. She left without receiving treatment. As of April 2001,
the hospital had not been fined.

• A patient went to the emergency room of Houston Medical Center in Warner Robins, GA, vomiting blood and complaining of a loss of appetite and a swollen and painful stomach. The patient’s symptoms indicated blood loss. He was treated with an IV solution, given prescriptions, and discharged. An ambulance returned him to the ER about five hours later, at which point he was in full cardiac arrest and died six minutes later. As of April 2001, the hospital had not been fined.

• Friends of a 15-year-old boy who had been shot in the abdomen dragged him into an alley next to Ravenswood Medical Center in Chicago and asked the hospital emergency room staff for help. The staff refused to go out to treat him or bring him into the hospital. After staff refused requests of police officers that repeatedly asked ER staff to come out and help, a police officer wheeled the boy into the ER in a wheelchair. Despite resuscitation efforts, the boy died. The hospital was fined $40,000.

Wolfe says that while the records reviewed by Public Citizen generally don’t reflect the reason a patient was dumped, often it is because the patient was uninsured. The law prohibits emergency room personnel from delaying screening or treatment to ask whether a patient has insurance, but personnel still do. Further, some HMOs require preauthorization for exams or treatment, and some HMOs refuse to pay for emergency room treatment later if the patient is found not to have a condition that constitutes an emergency. This often means the hospital gets stuck with the bill, providing hospitals with an incentive to dump uninsured or poor patients.

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